Surgical devices for imposing a negative pressure to stabilize the cardiac tissue during surgery

ABSTRACT

The invention is devices and techniques which use a negative (suction) pressure or vacuum, applied through a surgical instrument, to fix the position of a portion of the surface of a beating heart so that a surgical procedure can be more easily performed. The devices apply a negative pressure at several points on the outer surface of the heart such that a portion of the heart is fixed in place by the suction imposed through the surgical instrument. Because the instrument fixes the position of the tissue, and because the instruments remain at a constant distance from the particular portion of the heart where the surgery is being performed, the device may also serve as a support or platform so that other surgical instruments or devices can be advantageously used at the site. In certain preferred embodiments, the devices described herein have structures to facilitate the use of additional surgical instruments such that the placement of negative pressure device permit the surgeon to advantageously manipulate the other instruments during surgery. The negative pressure is preferably imposed through a plurality of ports which may be disposed in a substantially planar surface of the instrument which contacts the cardiac tissue.

The present application is a continuation of application Ser. No.09/440,106, filed Nov. 15, 1999 now U.S. Pat. No. 6,852,075 and titled“Surgical Devices for Imposing a Negative Pressure To Stabilize CardiacTissue During Surgery,” pending, which is a divisional of applicationSer. No. 08/870,687, filed Jun. 6, 1997, now U.S. Pat. No. 6,032,672,which is a divisional of application Ser. No. 08/603,328, filed Feb. 20,1996, now U.S. Pat. No. 5,727,569, each of which are hereby incorporatedby reference thereto, in their entireties.

Surgeries to treat disease in the heart, particularly blockages incoronary vessels, are becoming increasingly common and necessary totreat atherosclerosis and other conditions causing reduced blood flow tothe heart. For many years, surgeons have performed “open-heart” surgeryto repair defects in the heart and the associated cardiovascular system.As these procedures have become more common and more costly, a need hasdeveloped for techniques to make cardiac surgical procedures lesstraumatic to the patient. The necessity of attaching a surgical patientto a cardiopulmonary bypass (CPB) apparatus is a primary contribution tothe trauma inherent in traditional procedures. To attempt to alleviatethe trauma and side effects of CPB, surgeons have begun performingcardiac surgeries without stopping the heart. To successfully performsuch surgery, several challenges must be met. One particular problemconfronting the surgeon who operates on the beating heart is thedifficulty in performing extremely delicate surgical procedures whilethe contractions of the heart muscles cause the surface of the heart tocontinuously move.

To attempt to restrict the motion of heart at the particular area wherethe surgeon is working, the surgeon may pass at least a pair of suturesthrough the exterior tissue layers of the heart. By pulling the suturesin opposite directions, the tissue is stretched, and the motion causedby the contractions of the heart muscles is reduced or partiallycompensated. This technique is not completely effective in preventingthe natural motion of the heart and requires extra time to place thesutures, and, additionally, may cause damage to the cardiac tissue whenthe sutures are placed or manipulated. Preferably, the surgeon would beable to fix the motion of the cardiac tissue containing or adjacent toan area where surgery is to be performed without the need to attach ormanipulate additional sutures. The ability to fix the position of thecardiac tissue in a region of the heart would permit the surgeon toperform delicate surgical procedures on the beating heart while theportion of the heart on which the surgery is performed remainssubstantially motionless throughout the procedure.

SUMMARY OF THE INVENTION

This invention is devices and techniques which use a negative pressure(vacuum) applied through a surgical instrument, to fix the position of aportion of the surface of a beating heart so that a surgical procedurecan be more easily performed. The devices disclosed herein apply anegative pressure at several points on the outer surface of the heartsuch that a portion of the exterior tissue of the heart is fixed inplace by the suction imposed through the surgical instrument. Becausethe negative pressure introduced through the instrument -s the positionof a region of tissue, the instrument remains at a constant distancefrom the particular portion of the heart where the surgery is beingperformed. In this configuration, the device may also serve as a supportor platform so that other surgical instruments or devices can beadvantageously used at the site. In certain preferred embodiments, thedevices described herein have structures to facilitate the use ofadditional surgical instruments such that the placement of the negativepressure instrument permits the surgeon to advantageously manipulate theother instruments used during the surgery.

The negative pressure is preferably imposed through a plurality of portswhich may be disposed in a substantially planar surface of theinstrument which contacts the cardiac tissue. The ports are preferablyoriented such that the pressure is applied at several points over thetarget area to fix the position of the tissue and to reduce any traumato the tissue caused by the negative pressure.

DESCRIPTION OF THE FIGURES

FIG. 1 is an embodiment of the invention having a substantially annularhousing with a plurality of suction ports disposed about the peripheryof the instrument and having openings in the bottom surface whichcontacts the heart.

FIG. 2 is a dome-shaped or semi-spherical embodiment having a pluralityof suction ports disposed about the periphery of the bottom surface andhaving several instrument ports in the dome portion through whichadditional surgical instruments may be introduced, positioned, ormanipulated.

FIG. 3 is a section of a substantially circular embodiment showing apreferred configuration for the suction ports and a pressure conductingchamber for introducing the negative pressure to each suction port.

FIG. 4 is an embodiment of the instrument, in use, which is fixed on thesurface of the heart and has additional surgical instruments operablyassociated therewith to facilitate a graft being inserted to form ananastomosis between the internal mammary artery (IMA) and the leftanterior descending (LAD) artery.

FIG. 5 is an alternative embodiment of the invention wherein the suctionports for imposing the negative pressure are affixed to a shaft whichmay be part of a hand-held device and are contained in a block where aplurality of individual suction ports are arranged in an array.

FIG. 6 is a plurality of suction ports contained within a block havingattached thereto a pair of vacuum lines for introducing a negativepressure to each suction port.

FIGS. 7 and 7A are sectional views of the block showing an alternateconfiguration for the suction ports and the pressure conducting space.

FIG. 8 is an alternative embodiment for an array of suction ports havingvacuum tubes which run the length of the block and are oriented to besubstantially perpendicular to a passage space leading to each suctionport.

FIGS. 9 and 9A are a hand held instrument having a removable block,wherein the instrument has a receiving means to reversibly receive theblock.

DETAILED DESCRIPTION OF THE INVENTION

This invention is surgical instruments and techniques whichadvantageously apply a negative pressure to the surface of the heart sothat a portion thereof is maintained at a fixed position during asurgical procedure. The negative pressure is introduced to theinstrument and is applied at several points over the surface of theheart proximate to or surrounding the portion of the heart whoseposition is desired to be fixed during the procedure. The instrumentsfeature several suction ports which are brought into contact with theheart, followed by the application of a negative pressure through theinstruments, to fix the position of the tissue based on the placement ofthe instrument. The Instruments may also contain a sealed, airtight,pressure conducting chamber for operably connecting to a pressure inletfor communicating the negative pressure to the suction parts.Alternatively, each suction port may have a dedicated vacuum lineattached thereto.

The shape of the instrument may be varied depending on the particularapplication or the clinical diagnosis for an individual patient. In someembodiments, the shape of the instrument is defined by a housing forminga complete or partial, substantially annular, ring having the suctionports disposed about the periphery of the bottom surface of the housing.The suction ports are contained within the base of the instrument andthe opening of the suction ports are contained in the bottom surface ofthe instrument which may be substantially planar or may be shaped toconform to the surface of the heart.

In another embodiment, the operative portion of the instrument may bedefined by one or more arrays of suction ports which are substantiallylinear. The suction ports may be contained in a block which has at leastone vacuum line attached thereto. This design is particularly suitablefor an instrument having a shaft affixed thereto for positioning theblock containing the suction ports. The shaft may be fixed to a rigidsupport during the procedure or may be part of a hand-held instrumenthaving a handle structure adapted to be grasped by the human hand. In apreferred embodiment, the hand-held instrument contains a pair of shaftshaving a block and suction port assembly at each end thereof. The shaftsare connected at an intermediate portion by a pivot which allows thesuction port assemblies to move relative to one another, to be orientedand manipulated by hand, and to be locked into place in a desiredconfiguration.

An embodiment having more than one movable member in which suction portsare contained offers the advantage that a negative pressure may be firstimposed through the suction ports of each movable member to fix thetissue, followed by manipulation of the individual members which causesthe tissue to be stretched or oriented such that one portion of thecardiac tissue is fixed in position by one movable member and can beoriented relative to another portion fixed by a second movable member.

The negative or vacuum pressure imposed may be varied depending on thedesign of the instrument, the orientation of the ports, and the amountof pressure needed to hold a particular region of the heart in place.When manipulating the instruments of this invention, it is not, desiredto exert a downward force on the instrument once the instrument engagesthe cardiac tissue because the tissue could be damaged by being drawninto the suction ports, thus risking interruption of blood flow andischemic or reperfusion injury to the cardiac tissue. However, once anegative pressure is imposed, the instrument may be drawn away from theheart such that the portion of the surface tissue fixed by the suctionports is slightly elevated relative to the remainder of the heart.

Referring to FIGS. 1 and 3, an embodiment of the invention is aninstrument comprised of an annular housing 1 which could have analternate shape depending on the design and clinical application of theinstrument. For example, the body of the instrument has a housing whichmay be a portion of a circle, an oval, semi-oval, U-shape, or linearmember.

The portion of the housing 1 which contains the suction ports 2 has abottom surface 6 which rests against the surface of the heart andtherefore should be substantially planar or curved to the extentnecessary to simultaneously bring the suction ports 2 into conformingcontact with the heart. Referring to FIGS. 1 and 3, one embodiment ofthe invention has suction ports 2 equally spaced about the circumferenceof the housing 1. For purposes of stability, it is preferred that eachsuction port 2 be substantially equidistant from each adjacent port andspread over the entire portion of the instrument at the points ofcontact to the heart so that the instrument is more stably affixed tothe surface of the heart when a negative pressure is imposed. Asdescribed in detail below, the housing 1 may also have one or moreinstrument ports 9 to facilitate introducing a surgical instrument tothe site of the surgery to function on or in proximity to the fixedportion of the cardiac tissue.

The interior of the housing 1 may be further comprised of a means forintroducing a negative pressure to the suction ports 2. For example,each suction port 2 may have a dedicated vacuum line 3 for introducing anegative pressure to each suction port 2. However, it is preferred thata single vacuum line 3 introduce the negative pressure via an inlet 5which leads to an airtight, sealed, and pressure conducting chamber 4contained within the annular housing 1 which in turn communicates thenegative pressure to each suction port 2. Thus, by connecting a negativepressure source to the inlet 5, the negative pressure is introduced tothe instrument through inlet 5, thereby creating a negative pressure inthe pressure conducting chamber 4 which is communicated to each suctionport 2. The housing may also have at least one instrument port 9comprised of an opening that preferably traverses the width of thehousing and is shaped to receive an instrument. In use, the surgeon mayadvantageously rely on the housing 1 as a platform for other instrumentswhich may advantageously be used at the portion of the heart fixed inplace by the negative pressure. The instrument port 9 may be a simpleopening in the housing I or may be designed to operably receive aspecific instrument as described in more detail below.

In use (See FIG. 4), the instrument is gently positioned on the surfaceof the heart by manipulating the position of the housing 1 such thateach suction port 2 rests against the cardiac tissue. Once theinstrument is positioned on the surface of the heart, the negativepressure is applied through vacuum line 3 and inlet 5 while the housingmay be gently manipulated to insure that the negative pressure iscausing the cardiac tissue to become fixed to each suction port 2. Oncethe suction ports become functionally attached to the surface of theheart, the portion of the surface of the heart becomes fixed relative tothe instrument. Once the negative pressure is applied, the instrumentmay be attached to a stable support such as a rib retractor or otherstructure which does not move relative to the beating heart.

Referring to FIG. 2, a dome-shaped or semi-spherical embodiment of theinvention has a plurality of suction ports 2 spaced about the peripheryof the bottom surface 6 of the dome portion 8 such that the entireinstrument is fixed to the cardiac tissue at the point of each of theseveral suction ports 2. As with the above embodiment, it is preferredthat each suction port 2 be pneumatically connected via an air-tightpressure conducting chamber 4. The base of the instrument is comprisedof a substantially flat bottom surface 6 wherein the opening of each ofthe suction ports 2 is flush at the bottom surface 6. The bottom surface6 is preferably substantially flat because the bottom surface 6 willengage the surface of the heart when the negative pressure is imposed.Alternatively, depending on the size of the instrument and the locationof placement on the surface of the heart, the bottom surface 6 may becontoured so that the suction ports 2 may engage a curved surface of theheart. The bottom surface 6 may also have a separate contact layer 7 tocushion the contact between the instrument and the heart tissue and tofacilitate forming a tight seal when the negative pressure is imposed.The contact layer 7 may cover substantially the entire bottom surface 6proximate to the openings of the suction ports 2. If the materialsurrounds the openings of the suction ports, it is preferable that thematerial not be air permeable to prevent the negative pressure frompassing through the contact layer 7. Also, the contact layer 7 may beattached at the periphery of the bottom surface 6. The availablematerials for the contact layer 7 include the well-known andcommercially available medical plastics such as TEFLON®, silicone, andothers which are pliable and biocompatible.

The dome-shaped or semi-spherical embodiment of the inventionadvantageously has at least one instrument port 9 which may be placed inany of several locations but which is preferably located in the domeportion 8 of the apparatus. The instrument port 9 facilitatesintroducing the functional portion of an instrument 10 into the interiorof the dome portion 8, such that the instrument 10 can perform any ofseveral functions on the cardiac tissue. The instrument 10 could includea cutting apparatus, visual means, such as a scope or light, suturinginstruments, suction, blowing, or irrigation apparatus or any likeinstrument used during a surgical procedure. Multiple instrument ports 9disposed in the dome portion 8 allow several instruments 10 to beintroduced to the surgical site from numerous directions and to be fixedin place relative to the heart.

The instrument ports 9 may be comprised of only a simple opening in thedome portion 8. Alternatively, the instrument ports 9 may also have aflexible or rigid shaft 11 or other attachment means fixed to the domeportion 8 to facilitate introducing an instrument or a member associatedtherewith such as wires, tubes, cables which comprise or are used toperform the function of the instrument 10. The shaft 11 may alsocomprise the inlet (not shown) for introducing negative pressure to thepressure conducting chamber 4. Because the dome portion 8 remains at afixed distance to the heart, the instrument ports 9 or shaft 11 may havea collar 23 or stop associated therewith such that the distance betweenthe instrument 10 and the heart can be predetermined and fixed by, forexample, abutting a stop 12 a on the instrument 10 against a stop 12 bor collar on the instrument port 9.

The instrument ports may also contain a locking means which may bemagnetic or suction-driven so that the instrument 10 can be locked intoplace on the dome-portion 8. For example, the surgeon may view theprocedure via a scope 22 which communicates an image to a video monitor.This invention may be advantageously used to establish and maintain anoptimal position for the scope by inserting the scope 22 through theinstrument port and then fixing the position of the scope 22. The end ofthe scope 22 may have a collar 23 or other stop mechanism near its end,such that the scope 22 may be introduced through the instrument port 9wherein the movement of the scope 22 toward the heart is terminated bythe contact between the collar 23 of the scope 22 and the periphery ofthe instrument port 9.

Referring to FIG. 3, a sectional view through line A-A at FIG. 1 showsthe interior of the pressure conducting chamber 4 and associatedpassages or conduits associated with the suction ports 2 such that thenegative pressure in the pressure conducting chamber 4 is introducedfrom vacuum line 3, via inlet 5, and ultimately to the suction ports 2.The suction ports 2 have a substantially circular opening 12 disposed inthe bottom surface 6. Although this embodiment has a single inlet 5 suchthat the pressure is introduced to each suction portion 2 via thepressure conducting chamber 4, one or more of the suction ports 2 mayeach have an independent inlet 5′ for a separate vacuum line 3′.

As noted above, the suction ports 2 are disposed within a bottom surface6 which is preferably substantially flat. As noted above, the bottomsurface 6 of the housing 1 may be a continuous ring or other annularshape which contacts the heart about the entire periphery of housing 1,but may also be comprised of a plurality of individual bases 13 whichcontain the one or more suction ports 2 and which contact the heart atseveral independent points which may be co-planar or which may beadapted to the contours of the heart.

Referring to FIG. 4, FIG. 4 shows an embodiment of the invention in usein a coronary artery bypass graft (CABG) procedure where an anastomosisis formed between the internal mammary artery IMA 13 and the leftanterior descending artery LAD 14 and which is held open by vesselretractors 16 a and 16 b. One end of the anastomosis is sewn to the LAD14 by sutures 17 being manipulated by instrument 10. A vacuum line 3 isattached to inlet 5, to introduce a negative pressure to the pressureconducting chamber 4. An instrument 10, which in this example ismanipulating suture 17 for sewing the anastomosis at the LAD 14, isintroduced via instrument port 9 a located in the housing 1 of theapparatus. An instrument port 9 a has a shaft 18 disposed within theinstrument port 9 a to facilitate positioning the instrument 10 relativeto both the housing 1 and to the surgical site. The shaft 18 traversesall or a portion of the instrument port 9 a and may be flexible suchthat the shaft 10 can be oriented in a fashion to direct the instrument10 to the desired point within the surgical field. The shaft 18 may alsobe incorporated into a pivot 24 of any of several configurationsincluding a ball 25 and socket 26 joint having a passage 27 runningaxially through the ball 25 wherein the shaft 18 is contained in thepassage 27 such that the ball 25 is rotated within the socket 26 torotate the instrument 10 about the pivot 24 to position the functionalend of the instrument 10. An example of another instrument 19 isinserted through instrument port 9 b by passing the instrument 19through a rigid or flexible shaft 12 which is disposed within theinstrument port 9 b. In this example, the instrument 19 passes throughthe shaft 12 such that the position of the functional end of theinstrument 19 is fixed. In the example shown in FIG. 4, the instrument19 is being used to grasp the IMA 13 proximate to the attachment of thegraft.

Referring to FIG. 5, pursuant to this invention, the suction ports 2 maybe incorporated into a hand-held apparatus 20 having a shaft 21 attachedto a suction part assembly 22 containing the suction ports 2, at leastone vacuum line 3, and a block 23 wherein the suction ports 2 arecontained. This embodiment may be operated by a surgeon or surgicalassistant by hand grips 24 or the hand grips 24 may be replaced by aconventional attachment (not shown) for fixing the shaft 21 to a stablesupport such as a surgical retractor or other such fixed structureavailable during the surgical procedure. In a preferred embodiment, apair of shafts 21 are interlinked by a pivot link 25 at an intermediatepoint in the shaft 21 such that each suction port assembly may bepositioned independently of one another either before or after thenegative pressure is applied. In this configuration, the cardiac tissuewhich is functionally attached to the instrument at the points ofcontact with the suction port assembly 22 may be drawn apart by imposinga negative pressure through the suction ports 2 and then manipulatingthe rigid shafts 21, or hand grips 24 of the instrument 20 such thateach suction port assembly 22 is moved a distance from the other. Thesuction port assembly 22 is comprised of the block 23, in which thesuction ports 2 are contained, and a receiving means 29 located at theterminal (lower) end at the shaft 21 which is shaped to receive theblock 23 and to pen-nit introduction of the negative pressure fromvacuum line 3 to the suction ports 2 contained within the block. Thenegative pressure is preferably, imposed by one or more vacuum lines 3which may run parallel to the shaft 21 before terminating in the block23 containing the suction ports 2 or at any convenient point in thesuction port assembly 22. In a preferred embodiment, the blocks 23 aresubstantially rectangular structures wherein the suction parts 2 areplaced in an array as described below.

Referring to FIG. 6, the block 23 is comprised of a plurality of suctionports 2 which are connected to vacuum line 3 to create a negativepressure at each suction port 2. The number of individual vacuum lines 3may be any number less than or equal to the number of suction ports 2.An individual suction port 2 may be connected to negative pressure viathe pressure conducting space 4 (See FIG. 7A) or by a passage 26 whichcommunicates an individual suction port 2 directly to the vacuum line 3.The passage 26 is preferably smaller in circumference than the openingof the suction port 2. In the embodiment of FIG. 6, every other suctionport 2 is connected to either of two vacuum lines 3 which traversesubstantially the length of the block 23. Alternatively, each suctionport may also be connected to a single suction line as shown in FIG. 8.In the embodiment of FIG. 6, the passages 26 are oriented off-center tothe circumference of the opening of the suction port 2. In a preferredembodiment, the block 23 is a separate molded rubber unit which isconfigured to fit reversibly into a receiving means 29 at the terminalend of the shaft 21. In this configuration, the suction port assembly 22may be disassembled and the block 23 disposed after a single use.

Referring to FIG. 7, a sectional view of the block 23 through line B-Bof FIG. 6 shows the suction ports 2 disposed with the block 23 in alinear array such that each suction port is equidistant from eachadjacent suction port 2. The openings 12 of the suction ports 2 areflush with the bottom surface 6 of the block 23. In this embodiment, apair of vacuum lines 3 connects each suction port 2 to negative pressurevia a single passage 26 which runs from the vacuum line 3 to the suctionport 2 and is substantially perpendicular to the vacuum line 3.Alternatively, as shown in FIG. 8, a single vacuum line 3 may connecteach suction port 2 to negative pressure.

Referring to FIG. 7A, the block 23 may also have an inlet 5 whichintroduces the negative pressure to the suction ports 2. The suctionports 2 are disposed within the bottom surface 6 of the block 23 whichis to be affixed to the end of the shaft 21 (see FIG. 5). As will bereadily appreciated, the negative pressure can be introduced to thesuction ports 2 by a variety of techniques as described above. Thevacuum line 3 may be attached to the apparatus 20 at several points suchas the individual suction ports as illustrated in FIG. 7 or via a singleinlet 5 and communicated to each suction port 2 via pressure conductingspace 4 (FIG. 7A) such that the negative pressure is introduced to theblock 23 and communicated to each suction port 2. Thus, the objective ofcommunicating the negative pressure to the suction ports 2 to fix theposition of the cardiac tissue may be achieved via several alternatetechniques which are based on or may be developed from the embodimentsdisclosed herein.

Referring to FIGS. 9 and 9A, as noted above the block 23 may beremovable from the apparatus 20. The terminal end of the apparatus 20has a receiving means 29 which is adapted to reversibly receive theblock 23. In a preferred embodiment, the receiving means 29 is comprisedof a substantially parallel walls 27 having a grip means 28 associatedtherewith to maintain the position of the block 23 in place whenattached to the receiving means 29. The grip means 28 may be one ofseveral alternate designs. For example, the block 23 may have a ridge orindentation 30 which runs along the lateral exterior surface of theblock 23 and fits conformingly in a groove or ridge 31 formed in theinterior face of the wall 27.

The particular examples set forth herein are instructional and shouldnot be interpreted as limitations on the applications to which those ofordinary skill are able to apply this invention. Modifications and otheruses are available to those skilled in the art which are encompassedwithin the spirit of the invention as defined by the scope of thefollowing claims.

1. A method of guiding an instrument relative to an outer surface of aheart, comprising the steps of: providing an instrument guide having aplurality of suction ports open to a bottom surface of the instrumentguide; locating the suction ports in proximity to a target area to betreated; applying a negative pressure through the suction ports, therebyapplying negative pressure directly to an outer surface of the heart andfixing the instrument guide to the outer surface of the heart;introducing at least a portion of the instrument into said instrumentguide by traversing a side wall of the instrument guide, such that alocation of said at least a portion of the instrument relative to thetarget area is maintained by said instrument guide; and treating thetarget area with said instrument.
 2. The method of claim 1, furthercomprising introducing at least a portion of a second instrument intosaid instrument guide such that a location of said at least a portion ofthe second instrument relative to the target area is maintained by saidinstrument guide.
 3. The method of claim 2, further comprising treatingthe target area with said second instrument.
 4. The method of claim 2,further comprising illuminating the target area with said instrument. 5.The method of claim 2, wherein said first and second instrument portionsare introduced at different locations of said instrument guide.
 6. Themethod of claim 5, wherein said first and second instrument portions areintroduced through first and second instrument ports in said instrumentguide.
 7. The method of claim 1, wherein said treating comprisesilluminating the target area.
 8. The method of claim 1, furthercomprising fixing said instrument guide to a stable support.
 9. Themethod of claim 8, wherein said fixing comprises fixing said instrumentguide to a rib retractor.
 10. The method of claim 1, wherein saidtreating comprises at least one of: cutting, illuminating, suturing,suctioning, blowing and irrigating.
 11. The method of claim 1 whereinsaid instrument comprises a surgical instrument.
 12. The method of claim1, wherein said introducing comprises introducing said at least aportion of said instrument into an attachment means fixed to saidinstrument guide.
 13. The method of claim 1, wherein said introducingcomprises introducing said at least a portion of said instrument into aflexible or rigid shaft fixed transversely with respect to a main bodyof said instrument guide.
 14. The method of claim 1, further comprisinglocking a position of said at least a portion of an instrument relativeto said instrument guide.
 15. The method of claim 1, wherein the heartis beating.
 16. A method of guiding an instrument relative to the outersurface of a heart, comprising the steps of: providing an instrumentguide having a plurality of suction ports; fixing the instrument guideto the outer surface of the heart, in proximity to a target area to betreated, by applying a negative pressure to the outer surface of theheart, through the suction ports in fluid communication with the outersurface of the heart; and introducing at least a portion of theinstrument into said instrument guide by traversing a side wall of saidinstrument guide such that a location of said at least a portion of theinstrument relative to the instrument guide is maintained by saidinstrument guide.
 17. The method of claim 16, further comprisingtreating the target area with said instrument.
 18. The method of claim16, further comprising positioning said at least a portion of aninstrument relative to the target area.
 19. The method of claim 18,wherein said positioning comprises manipulating a shaft attached to saidinstrument guide, through which said at least a portion of an instrumenthas been inserted.
 20. The method of claim 17, wherein said treatingcomprises at least one of: cutting, illuminating, suturing, suctioning,blowing and irrigating.
 21. The method of claim 16, wherein saidinstrument comprises a surgical instrument.
 22. The method of claim 16,further comprising fixing said instrument guide to a stable support. 23.The method of claim 22, wherein said fixing comprises fixing saidinstrument guide to a rib retractor.
 24. The method of claim 16, furthercomprising locking a position of said at least a portion of aninstrument relative to said instrument guide.
 25. A method of guiding anoperative element relative to the outer surface of a beating heart,comprising the steps of: providing an instrument guide having aplurality of suction ports; applying a negative pressure to the suctionports, thereby fixing the instrument guide to the outer surface of thebeating heart; and introducing at least a portion of the operativeelement into said instrument guide by traversing a side wall of theinstrument guide such that a location of said at least a portion of theoperative element relative to the surface of the beating heart ismaintained by said instrument guide.
 26. The method of claim 25, whereinsaid operative element comprises a surgical instrument.
 27. A method ofguiding an instrument relative to the surface of a heart, comprising thesteps of: providing an instrument guide having a plurality of suctionports; locating the suction ports in proximity to a target area to betreated; applying a negative pressure to the suction ports, therebyfixing the instrument guide to the surface of the heart; introducing atleast a portion of the instrument into said instrument guide such that alocation of said at least a portion of the instrument relative to thetarget area is maintained by said instrument guide; introducing at leasta portion of a second instrument into said instrument guide such that alocation of said at least a portion of the second instrument relative tothe target area is maintained by said instrument guide; and treating thetarget area with at least one of said first and second instruments. 28.A method of guiding an instrument relative to an outer surface of aheart, comprising the steps of: providing an instrument guide having aplurality of suction ports; locating the suction ports in proximity to atarget area to be treated; applying a negative pressure to the suctionports, thereby fixing the instrument guide to the outer surface of theheart; introducing at least a portion of the instrument into saidinstrument guide by traversing a side wall of the instrument guide, suchthat a location of said at least a portion of the instrument relative tothe target area is maintained by said instrument guide; and treating thetarget area with said instrument, wherein said treating comprisesilluminating the target area.
 29. A method of guiding an instrumentrelative to the outer surface of a heart, comprising the steps of:providing an instrument guide having a plurality of suction ports;fixing the instrument guide to the outer surface of the heart, inproximity to a target area to be treated, by applying a negativepressure to the suction ports; introducing at least a portion of theinstrument into said instrument guide by traversing a side wall of saidinstrument guide such that a location of said at least a portion of theinstrument relative to the instrument guide is maintained by saidinstrument guide; and fixing said instrument guide to a stable support.